REBROADCAST: At Great Circle Recovery, the doors are open to anyone seeking addiction treatment

Fentanyl has taken over the illegal drug market largely due to its low cost and abundant supply. It’s fueling rising addiction rates, and those in need of treatment often have no options. Enter the Confederated Tribes of the Grande Ronde’s Great Circle Recovery program. Great Circle runs two clinics in Portland and Salem, as well as a mobile clinic. It serves not just tribal members, but anyone who’s struggling with addiction and wants help.

We hear more about the nonprofit’s mission and how the program works from Executive Director Kelly Rowe, Medical Director Dr. James Laidler and Operations Director Jennifer Worth. We also talk with James Smith, a urinalysis technician at Great Circle who is working to become one of their peer mentors; as well as Albert Mendez, who is in recovery and receives regular treatment from the clinic. Oregon Health Authority’s Behavioral Health Director Ebony Clarke also joins the conversation.

The show is part of the series funded by the Oregon Community Foundation that examines some of Oregon’s biggest problems and possible solutions.

This transcript was created by a computer and edited by a volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. By most accounts, the opioid crisis has become a fentanyl crisis. It’s fueling addiction and overdoses and people in need of treatment often have no options. Enter the Confederated Tribes of Grande Ronde. They started their Great Circle Recovery Program in Salem two years ago and recently opened a second clinic in Portland. We wanted to understand what this work looks like right now. So we met up with Executive Director, Kelly Rowe, Operations Director, Jennifer Worth, and one of their clients, Albert, who’s been in recovery for about a year. We were in a meeting hall at Saint Anthony’s Catholic Church which is around the corner from Great Circle.

I started with Kelly Rowe. I asked why they opened the first clinic two years ago.

Kelly Rowe: At Grande Ronde, the Tribe had been noticing the epidemic happening. We have Tribal members that we have sent forward for treatment for years, decades, really. We’ve spent millions of dollars on our Tribal members in residential treatment and had a lot of recidivism. A lot of people relapsing. They’d come back to the community and they would relapse and we don’t give up on our Tribal members. We are always looking to take care of our people. We love our Tribal members and we want to help them, but we would see them relapse and know that we were not able to help them.

So we started looking at how could we bring treatment to our people and do it in a way that we had more ability to control and why are we not doing this ourselves? It’s always kind of something that had been on my radar since I came to the Tribe. When we started looking at doing opioid treatment services, I had reached out to some people that I knew in programming for this and said, ‘Who do you know that could help us stand up a treatment program?’ They had referred me to Jennifer [Worth] and I met Jennifer here in Portland. We had tea and we started talking and we started dreaming and looking at, ‘what would it take?’

The regs are probably about three inches thick and that’s just the federal regulations. We started trying to figure out how would we do this, what would be the programming needed? What do we need to do to be able to help our people? Could we do it in a way that makes the most sense that isn’t just a ‘dose and go’ program, but is something that truly would help, not just the Grande Ronde Tribal members, but would really help the community around it because we know that people are not successful unless there is a community of recovery around them. So that’s what started our programming.

Miller: Jennifer, what’s a ‘dose and go’ program? What didn’t you want to do?

Jennifer Worth: So it was really important to Kelly and to the vision of the Confederate Tribes of Grande Ronde to create services that had additional support. So for instance, we have a shower / laundry trailer on-site. We think about the other needs that lead to people struggling with opioid addiction. We try to look at how to help navigate those barriers and we meet people where they’re at. So really thinking about food, hygiene, some of the very basic things that cause them to struggle, and figuring out how to take those barriers and make them less stressful for them to start getting to a place where they can get treatment and be less at risk of an overdose.

Miller: When you were in those early conversations, Jennifer, when you were designing the way the clinic would work and what elements you would include, what was foremost on your mind? I jumped ahead to this phrase because that was sort of new to me. You didn’t want to be ‘dose and go.’ But what were your broad goals for what it would be?

Worth: I really wanted to work with Kelly to create an environment where when people walked in the door, whether they stayed or engaged in services or not, they felt seen,

heard, valued, and cared about the moment they walked in the door. Whether they engaged or not in services, they got that feeling so that when they were ready they would come back – because the most important thing is for people to feel seen and heard and cared about. In my experience, a lot of times, our population feels really stigmatized and just not cared about in the way that they deserve. I felt that was important and I wanted to bring that to the clinic. One of the things that I love about our Portland clinic is when you open the door, there’s this giant mural of the Willamette Falls that you see and it just really speaks to the Tribe’s values of embracing their people and the community and bringing people to making sure that people feel seen, heard, and valued. So I just wanted to make sure that we put that into our design.

One of the other things - Kelly helped me with this - is the Camas flower, which is really important. So when you walk into the clinic all around the floor we have Camas flowers designed into the floor and that’s just to kind of bring some more of that element that’s part of Grande Ronde to anybody that comes into our program.

Miller: I’m curious about that ‘anybody,’ Kelly, that the Oregon Health Authority has said that American Indian / Alaska Native and Black communities in Oregon experience dramatically higher rates of overdose deaths than other groups. Who do you serve here?

Rowe: So we serve everybody. For us, our mission is for American Indians, Alaskan Natives. But we serve everybody. Our mission is to see our Tribal members because we’re the Tribe, but we know that successfully treating the community is important. We want to serve everybody that is suffering from opioid use disorder because that’s the only way that we can help people and make people well and to heal people. And with Great Circle Recovery, that’s what we’ve been able to do, is really get out there and reach out and make people aware of the services and programs that we’re offering. Make it something that is bigger than just the medication and that it’s bigger than… just like Jen said, we have programming that really reaches out and people feel it when they come in. It’s that we care about you, that it’s something that has been told to us more than once when people come in. They’re like, ‘This feels different, this feels very welcoming.’ That’s exactly what you were going for.

We wanted people to have that feeling of respect because when people, especially just walking in the door, is that first barrier. When somebody is struggling with opioid or any kind of addiction, having the courage to come through and ask for help is huge. When they are able to just come through the door and ask for help, we want to be there and we want people to know that the stigma, there is none. We love you. We want to be there for you and we’re here and that feeling to be able to communicate it without saying anything is the most important thing. So we are here for the community.

Miller: Well, Albert is with us right now and we’ve heard a lot already about the moment of first walking through the door. You did that about a year ago at the clinic in Salem. Do you remember that first day? Do you remember when you were walking in?

Albert Mendez: Yeah. Kelly and Jen, I think both touched out on that. I think that I would say kind of like home, that feeling at home. Because I was homeless before I got there. So I didn’t feel a sense of belonging, I guess you could say, so that was a huge moment for me when I walked in. I didn’t feel judged and I was able to trust my counselor, her name is Crystal Grimes, who works with me. I feel like I could talk to her about anything. But yeah, that sense of community I think is a big part that keeps me going back there.

Miller: Can you tell us what your life was like before you walked through the door?

Mendez: Yeah, I was homeless. I’ve had struggled with opioids for 10 years, off and on, and other drugs also. But opioids was my biggest struggle, especially now with fentanyl being and everything. I think I had pretty much lost everybody around me. I think everybody’s trust. Nobody believed in me. Nobody trusted what I would say anymore. They’re just like, oh, yeah. Something, something again...

Miller: You’d burn those bridges?

Mendez: Yeah. Exactly. Yeah, I’d burned those bridges already. I was homeless and my cousin actually went to Great Circle before me and he’s the one that told me about it and he was like, ‘Yeah, it’s a great place,’ and I had never tried the medication, methadone. So he’s the one that tried it first and told me about it and I was like, ‘You know, if it works for him and then it’s something that probably would work for me.’

Miller: Before you heard that, from your cousin, what were your thoughts about medication-assisted treatment, about methadone specifically?

Mendez: No. I don’t think I ever thought it was possible.

Miller: Getting off of using, whether it was heroin or at that point?

Mendez: Yeah, Opioids. Yeah. I never thought it was possible to get off like that, it was something that I had struggled with and tried to cold turkey or try to wean it off with different, different drugs, weed, marijuana. But yeah, I didn’t think it was possible.

Miller: So you’d sought treatment in other ways over the course of that decade and they hadn’t worked?

Mendez: Yeah.

Miller: What was it like when you started talking with your counsel? You mentioned her name is Crystal? What was it like when you started opening up with her and meeting with her regularly?

Mendez: Well, I’m kind of really shy so I’m really quiet and I kind of just stick to myself and, I don’t know, for some reason I got that feeling that I could trust her and open up to her. So it took me a second, but they do other services too and have groups and stuff. So I was going to one of her groups and stuff and slowly building that kind of trust talking to her and sharing what was really going on with me and be able to admit that there was something serious, that I couldn’t handle it alone. It was something I was gonna need help with overcoming, this addiction.

Miller: What’s an average day like for you right now?

Mendez: Right now? I’m working. So that was huge for me. I wasn’t able to hold the job down just with the withdrawals and stuff from the drug use. It was impossible to hold down a job. So right now I’m working. I work graveyards so I sleep during the day, kind of wake up, go to the clinic, go get my medication and stuff, and squeeze in a group here and there whenever I can.

Miller: How has it been working the graveyard shift? How has that worked with your sobriety?

Mendez: For me, I think it’s helped me out a lot because I’m sleeping during the day so it kind of gives me a little chance not to have as much free time, I guess, on my hands.

Miller: And nighttime you’re working, so you’re less likely to get in trouble then?

Mendez: Yeah. Exactly. Yeah, I’m at work so I’m busy and by the time I get off, I’m tired. So I just wanna go home and get some rest.

Miller: Jennifer, to go back with you, what role does methadone, which we’ve been talking about, but also suboxone, what role do they play in the work you do at these clinics?

Worth: It’s a tool in what we use and it’s a really important tool with the opioid crisis and especially with fentanyl. Fentanyl just flipped kind of everything on its head in terms of use. We see younger and younger severe addiction and then even older there’s this broad spectrum of who is impacted by severe opioid use disorder.

I think that it’s really important for clinics like ours to be seen as part of recovery and we need to just understand that it’s just like any other medication and take the stigma out of methadone because methadone saves lives. Especially in a fentanyl crisis or an opioid crisis, like we have right now across the country. So the medication is what opioid treatment programs are centered around. When the Tribe built this opioid treatment program, Great Circle, they wanted the medication to be there and then the other services as well and all OTPs [Opioid Treatment Programs] are required to have counseling services and different things…

Miller: …Opioid Treatment Programs…

Worth: Mhmm. They have certain regulations of what they have to do. So we follow all those guidelines, but we also just have kind of the idea that more services are important, more recovery services, more relapse prevention services. We have an area we call the recovery center that we’ve added on to the OTPs where we do acupuncture and some other things as well. We have a career area. So people who are starting to kind of get a little more stable can come and search for jobs. Just again, going back to the basics.

Miller: Kelly, what’s culturally-specific and tied to the Grande Ronde’s long traditions? What comes from those traditions that is a part of the programming here?

Rowe: So ‘culturally-specific’ is really focused on building up on the person’s spirituality and really trying to reach back into that person and showing them that everybody’s worthy, and there is hope. And the idea that no matter where you’ve been and what you’ve done, that you are lovable and that you are, there’s hope, that we want you to come back no matter how many times it takes that if you relapse that it doesn’t matter, we want you back, we want you back every time because we don’t want to lose you, that we love you. And it’s important for you to come back to us.

Worth: So in terms of being culturally responsive, we offer smudging as part of it. Our operations model is kind of built on that ‘whole-person centered care.’ A Medicine Wheel is the foundation of our operating model. Then we have to kind of wait until our people stabilize a little bit before we can pull in all of the different cultural pieces. But we’re starting to work on different groups. We have several specific groups that we offer that are culturally-specific.

We have a mobile unit that we actually take out to the Reservation and we coordinate a lot with our Health and Wellness Program that’s out there for any of the more in-depth cultural services. But we do integrate those into the opioid treatment program. Now that we’ve been stabilized in Salem, we’re starting to integrate a little bit more. But we had to be really cautious in the beginning because we were integrating a Western medicine and a new culture. So we were taking it very slow.

Rowe: Some of the things that we’re doing at Grande Ronde at the clinic out there - we do have a ‘Good Medicine Program.’ We do ‘Jams,’ where we’re doing drumming and singing and we’re doing some other things that are beating and weaving different things like. Eventually we want to be able to bring to the different clinics. However, some of it, we have to be really thoughtful of the timing of it and when it’s appropriate to bring it in. Like Jen said, it has to be at the right time, when people are ready for it, and it’s the right timing of it - I guess it’s the best way to say it. So we’re working with them constantly.

Miller: Kelly and Jennifer, you’ve both talked about making sure that if someone comes and then they’re not ready and they go and they come again and again and again, that each time, you wanna be ready for them when they are ready. How often might somebody come before they say, ‘I actually want to get treatment here?’

Worth: Starting and stopping is just part of the process, because addiction is not a straight line, recovery is not a straight line. Depending on what model you’re looking at, it’s like a spiral. So people go back and forth, back and forth, back and forth.

So in our program, we have restarts, stops, and starts constantly. We have people that will restart, I don’t know what, how many…15? About 15 times. And our thought is if they come in and they start and they come for a few days and they stop, the next time they come it’s gonna be a little bit longer. We make sure that they have Narcan relapse prevention tools, so when they leave they know that we’ll meet them right where they’re at when they come back in the door.

The other thing that’s important to know is if folks are still using, we want to see them more, especially if they’re using fentanyl. Because we want to have them in the clinic being seen every day. Looking at them, monitoring them, and giving them a known substance. Methadone is a known quantity, it’s a known substance. When we see them and we’re giving them medication, that’s one less fentanyl pill they’re taking on the street that day.

So it’s really important that we meet them where they’re at and that they know that they’re welcome back when they’re ready. We’re there and if they’re not ready, we’re also still there.

Miller: What you’re talking about is so much more complicated than I think an old - maybe never true, but still pervasive - idea of being ‘cured,’ of being in recovery. That is, ‘abstinence equals success.’ What does success mean to you? I’m actually curious to get all three of your takes on this but maybe Albert, first. I’m curious what that word means to you?

Mendez: I think it’s about how you respond when you’re knocked down – if you stay down or you get up. Because failure is gonna happen. It’s how you go about it that defines success for me. I think part of the reason why it takes a little bit longer is because they work with you to try to get the appropriate dosage for you with the medication, because everybody’s a little bit different. There’s a lot of different variables that go into it with recovery. So it takes a minute for them to find the appropriate dose of medication where you’re stable and you’re not getting the cravings or the urge to go out there and use again.

So coming back is important to get that feeling that it’s gonna happen and people not being disappointed in you and encouraging to continue. Because, as addicts, I think we’re used to getting the door shut on us and nobody believing that we’re capable of more.

Miller: Kelly. What about you? What does success mean from your perspective?

Rowe: Success is coming back and knowing that we are not judging and there’s no stigma for us. We know how powerful fentanyl, the opioid, the drugs are and that we are not looking down at anybody. We want them to come back, no matter what. That is success to me.

Miller: And Jennifer Worth?

Worth: I think for me it’s knowing there’s one less overdose. Just knowing that whether they’re still using or they’re working towards not dying when we have them come in and we see them, to me, that’s one less overdose. That’s why it’s so important to keep that door open and to limit different barriers that help people, from transportation to food insecurity, to all the things that, no matter what a problem is, you have to try to figure out those social determinants. So I just think one less overdose.

Miller: That was Jennifer Worth, the operations director at Great Circle Recovery. We also heard from Executive Director Kelly Rowe and Albert Mendez, one of their clients.

James Smith is a urinalysis tech at the clinic. Jim Laidler is the Clinic’s Medical Director. Dr. Laidler has been working in the field of addiction medicine for several years now, after a long career in pain management. He told us he has never seen anything like the current crisis.

Dr. James Laidler: The problem with it has been that it’s not only 100 times more potent than heroin but it has some features to it in that it is more rapidly addictive and harder to get rid of. Although it’s for the people who are using it, it seems to be a fairly short-acting drug because it’s so fat soluble, it stays around much, much longer at low levels in the body. So it makes it harder to start somebody on a medication like Buprenorphine or Suboxone

Miller: Because of the chemistry of fentanyl and the power of it.

Laidler: Right. The problem with Suboxone is that it’s both a blocking agent and also an opiate of its own, right? But if you give it to somebody who still has some of the opiate on board, you can have ‘precipitated withdrawal.’ So they’ll actually feel a lot worse, even though they may actually feel like they’re in withdrawal. We are having problems with people who had been abstinent for two or three days and felt like they were in terrible withdrawal when we start Buprenorphine, they’d actually feel worse. So we had to come up with some new strategies. It doesn’t mean that Buprenorphine doesn’t work. It does work in fentanyl, but new strategies are needed.

Miller: The phrase that we hear a lot when we talk about people treating substance use disorder and in other public health fields is ‘harm reduction.’ But I’m just thinking about what we were just hearing before the break from Jennifer Worth, that phrase seems so soft compared to the stakes right now. It seems like we’re not talking about harm reduction. We’re talking about death reduction.

Laidler: That’s the way I see it. Our job, first and foremost, is to get people some stability in their lives, so they stop pursuing the fentanyl and reduce their risk of death. There’s so many problems with fentanyl, but one of them is that unlike heroin - heroin, you could look at it and you could see the quantity of heroin you were getting. You could weigh it out. You knew or you might suspect that it might be diluted. But the problem with the fentanyl pills is that every pill might have - well, this is from the DEA - anywhere from 50 micrograms of fentanyl, which is a millionth of a gram, to 5 mg. So 100 fold range in their amount and they all look the same and there’s no way to tell. As I tell my patients, I said, ‘God only knows what you’re getting, because the person who sold it to you doesn’t.’

It looks like every other pill and it is literally Russian roulette. And I’m especially concerned about new users. People who are younger usually, trying it out for the first time because the lethal dose of fentanyl is 2 mg. Let’s consider the lethal dose for 90% of people who are opiate naive. So right now the average amount in fentanyl pills is 1.5 mg. So it’s right on that edge. So we have signs out in the Reservation saying ‘One pill can kill.’ I see it out around other places. It is absolutely true. You get that slightly stronger pill and that’s it. Just one is all it takes. So we are beyond ‘harm reduction’ and we are full on into ‘death reduction.’

Miller: James Smith is with us as well. You’re a urinalysis tech at Great Circle Recovery. What does that job entail?

James Smith: That looks like, when they first come in the doors, they start intake process and give them a UA to kind of see where they’re at and what kind of help they can get.

Miller: Meaning to see what’s in their system.

Smith: Yeah.

Miller: You’re the one who says, ‘Hey, I need you to pee in this cup.’

Smith: Yes.

Miller: What’s your approach to doing that?

Smith: Well, I’m a man in long term recovery too. So I feel like I know how to talk to addicts, I’m an addict myself. I just say, we’re gonna go pee, you need some water. I let them have some water where they need and just treat them right and nice.

Miller: What’s the purpose of that? And maybe Jim Laidler, this is a question for you. What do you do with the results of that first test?

Laidler: Well, there’s a couple of things. One is, it’s a state and federal requirement. So that’s part of it. But more importantly, it’s really just to see where we’re starting from – what the patient is using at the time. I mean, we assume that they’re using what they tell us they are. But sometimes people don’t really realize. It’s less now, but it used to be that we get people in who say, ‘Oh, I’m using heroin,’ and we do the test and say, ‘No, actually you’re using fentanyl.’ We still get people sometimes, ‘Oh, I’m just using Oxycodone,’ …they’re not, they’re using fentanyl. So that’s important to know.

Plus nobody these days is just using one drug. So there’s that. I mean, there’s other things we have to be concerned about. So if somebody’s also using benzodiazepines, for example, Valium, Xanax, that sort of group, those interact synergistically with all opioids, including methadone and can cause respiratory depression and death. So if somebody’s using benzodiazepines or barbiturates, which you don’t see much anymore, or alcohol, those all can react synergistically with methadone and increase the risk. So we need to be more cautious when we’re going up on the dose with those folks because they’re using these other compounds.

Some of it too, we just wanna make sure that we know that the person’s using what they think they’re using.

Miller: James, you mentioned that you are in recovery yourself. How did you end up at Great Circle Recovery?

Smith: Well, when I got clean and sober, I knew that that’s how it works. You wanna get clean and sober yourself and then help the next person get clean and sober. I kind of feel a lot of different places out. They weren’t really my fit and this place opened up. I thought it would be a good opportunity. Just the way it all works out is it almost like it was meant to be and it’s a good fit. I like working there.

Miller: How long have you been sober?

Smith: 23 months.

Miller: What was going on in your life before that?

Smith: Just like everybody else, there’s some layer. Something happens and then you pull that layer back and well, ‘it was this.’ For me, I was always pulled [into] toxic relationships. Behind that, my coping skill was to use or get drunk. That’s what I did. That’s the only skills I had, but not anymore.

Miller: Am I right? That you’d had 18 months clean? Then the day you went back to using, you OD’d on fentanyl?

Smith: Yeah.

Miller: I mean, that’s exactly what Jim Laidler was talking about.

Smith: Yeah, like I said, I only take one pill. I only took two hits off it and then I was out. Then I got Narcan’d a few times. That was my eye opener. I’m like, ‘Drugs are different, now.’ I’m not like this. There’s literally no joke. That’s the end result of drugs nowadays – is you die or you overdose.

Miller: So that changed your understanding of your options? Or at least it opened your eyes about the risks?

Smith: Yeah. That there is no gray area. You’re eventually gonna somethin’ bad, eventually gonna happen with fentanyl. And with the UA’s, I see the results and like you said, it’s not just one, it’s everything that they throw into those pills. It’s not a good game to play anymore.

Miller: My understanding is that part of your job, in addition to doing those UAs – the urinalysis – is to go out on the street to do outreach to get people to seek treatment. What were you looking for when you would see if you could find people to see if you could get them to seek help?

Smith: I mean, there’s obvious [signs], like the wounds and the swelling, just the look of the homeless people, and then it goes past that. You can look and see despair in their eyes and just a living situation…they’re low. The lows are really low nowadays.

Miller: Jennifer Worth, do you want to jump in?

Worth: We went to some areas where we know people are using fentanyl and we just handed out information and we were just talking to anybody that we could talk to about naloxone overdose prevention and just trying to do outreach.

Miller: So I’m curious at this point, my assumption would be that everyone you’re talking to… I mean, what would they say? I guess maybe this is my naivete, but I assume that they know what you’re telling them. They know what they’re doing could kill them but they’re addicted and maybe feeling helpless. But I guess I’m wondering, what do you think you can tell them that they don’t already know?

Worth: There’s not a lot we can tell them except that when they’re ready, there’s programs and just making sure they know where the resources are. A lot of the people we talked to, they all were talking to each other about [their] different experiences. Like, ‘Oh, I tried Sublocade, and this is what happened,’ ‘Oh, I tried methadone and this is what happened,’ ‘Oh, I tried Suboxone and this is what happened.’ And they would tell us their stories.

I just like hearing those stories because I think it’s important to understand the experience of the people that you’re trying to help. It’s really important. There’s not anything that I can tell them. It’s more about them feeling like people care about them and want them to get help. I think if they know that people care, like going back to that value that Grande Ronde has, it can do more.

Miller: Kelly, you wanna jump in too?

Rowe: I do. I think also what it does is it builds our credibility in the community and it builds it not just for Great Circle but it builds it out at Grande Ronde too. Because it allows for the mobile unit when we’re out with it in McMinnville and Sheridan that it’s getting that message out that if you don’t live in Salem or Portland, but you live in one of those outlying communities, that we have those mobile services also and that it’s something that you can access there.

Miller: James Smith, one of the issues that I think is connected to this and maybe was underlying one thing I was sort of curious about with Kelly and Jennifer is over the years, when we’ve talked to people in recovery, we’ve often heard that the person who is dealing with the addiction, it has to come from them first. That no matter how many times people talk to you, the desire to change has to first come from you. I mean, I’m wondering first of all, if that rings true to you?

Smith: Yeah, everybody’s always told me, ‘I went to prison, I went to treatment,’ but until something internally clicked in where I wanted to change, you’re not gonna do it unless you wanna do it for yourself. If you have a little bit of ‘want to,’ all you need is a little bit and then just start doing what other people do and go where other people go there, trying to stay clean. Then before you know it, you got 30 days, 60 days, 90 days… a year, you’re working. Just those things happen.

I think recovery is like a reward system. Like once we see the benefits... like for me, I’ve got my kids back, my apartment, job, all the things, and once you see these things that you get, the whole life slowly fades away. But you gotta keep it right in the forefront of your mind that bad things can happen. So it’s just like a fight and you got to win or lose.

Miller: Jim Laidler, what’s the hardest part of your job?

Laidler: Oh. Some of the hardest part is just getting people to realize how serious the problem has become. I think in the community, especially there’s this feeling that fentanyl is just sort of the same old, same old. It’s just heroin in a different wrapper. But I see fentanyl as being a real game changer.

For over 100 years, heroin was the ‘big dog.’ It was the big problem. I mean, my parents talked about seeing people using heroin back when they were in college. So, I mean, it’s really ancient. I’m not a young man. But then suddenly fentanyl came on and I’m afraid people have gotten so used to the idea that they know how to treat heroin and they’re just treating fentanyl like it was heroin, and it’s not. It’s a lot more potent. It’s a lot more addictive, it’s a lot harder to deal with.

On top of that, there are bigger and badder things coming. We’re already seeing them on the east coast: the Nitazene Family. So that’s a whole another group of opioids that’ll be here on the west coast before too long. There’s this multiplication of new drugs that are coming out and each of them has their own peculiarities, right? Now, we’re starting to see in the Portland area, in Salem, Xylazine, which has been a plague in Philadelphia and in New York, and now it’s here and that’s gonna be another problem we’re gonna have to deal with and have to deal with in new ways.

A lot of the old thinking about heroin isn’t gonna work because with fentanyl things are happening faster, people are addicted faster. One of the biggest problems we have is that it’s coming in this pill form. Whereas young people in their teens might have been a little put off the idea of smoking heroin or injecting heroin, pills [were] sort of traditionally how people started opiate addiction. We used to joke about you go raid grandma’s medicine cabinet and the pills have a very low barrier for young people. The problem is that this isn’t an oxycodone or hydrocodone. This is fentanyl and people are getting addicted rapidly and it’s extremely powerful and they get in deep quickly.

One of the things that was really gonna have to change in the community is the approach we have towards youth. That’s one thing we’re doing that’s a little different than a lot of the other clinics and that we will see people under the age of 18. Most places don’t. The problem is we’re now seeing people in their late teens who are heavily addicted to fentanyl and we will probably start seeing people in their mid-teens and their early-teens heavily addicted to fentanyl. If there’s no place for them to go then they’re gonna be dying. Right now, fentanyl overdose is the number one killer in people 18 to 45.

Miller: Nationwide?

Laidler: Nationwide and in Oregon. Yeah. So that’s something we really have to look at in a completely different way.

Miller: James Smith, what’s keeping you clean right now?

Smith: [Sighs heavily] Just my life. I like my life today.

Miller: And you wouldn’t have said that at earlier parts of your life?

Smith: No, I did meth for like 21 years. Just miserable. Oh, there were pauses where I put on a good facade and everything was good, but it was never really good because I never worked on the inside. Addiction starts from trauma and passed up and it all builds up and you gotta work on it. That’s what the good thing about Great Circle Recoveries, those counselors, they really, from the time you walk in those doors, everybody generally cares and that’s what we need to fight this.

Miller: That was James Smith. He’s part of the Great Circle Recovery Team doing urinalysis and outreach. We also heard from Medical Director Jim Laidler.

We end today with Ebony Clarke who is with us as well. She directs behavioral health services for the Oregon Health Authority. I asked her to give us a sense for the level of need statewide for substance use disorder treatment and the availability of that treatment.

Ebony Clarke: So that has to do with capacity and what I’ll say is that before the pandemic, there were issues with a lack of capacity in terms of access to care. Whether it was from the outpatient realm where someone could get community-based services once or three times a week, all the way up to residential or inpatient care. Then we experienced the pandemic which just exacerbated those issues. With the impacts of the pandemic and the workforce shortages, we’re at this all time high of not having enough capacity.

So right now, I’m thinking long and hard about residential levels of care and inpatient levels of care. And this is just a guesstimate, I’d say [from] the last report I saw, we need a minimum of 2,000 to 3,000 different types of bed capacity when we think about residential - whether we’re thinking about substance abuse disorder treatment or if we’re thinking about mental health, specifically. And then the middle, co-occurring [substance abuse with mental health]. When we then couple the issue with, ‘Ok, we have an organization that’s ready to provide services, we gotta hire, we have to staff up,’ and so then, because we’re in this workforce shortage, that delays the launching of services coming online…

Miller: Just to be clear, you’re saying 3,000 more than we have right now?

Clarke: Well, here’s what I can say: I know that there’s been a couple recent studies in the last year and a half and I know that there was a recent study that looked at the substance use continuum of care and it identified that we didn’t have enough residential beds specific to ‘SUDS,’ and so…

Miller: I’m sorry, that’s Substance Use Disorder?

Clarke: Yes, Substance Use Disorder Treatment Services. Because I’m four months into my new role and there’s been a lot of transition at OHA. Under the guidance and leadership of the new administration, Governor Tina Kotek, I’ve been tasked with actually facilitating a study between now and the end of this year to do a thorough assessment to really look at between substance use disorder and mental health residential capacity services, what do we really need? What do we have?

I’ll just say that in this current biennium, specific to ‘21-’23, there’s a number of additional beds that will be coming online and I’ll say that we’re anticipating in the next two years, we’ll have about close to 400 to 500 beds coming online. But again, because of the workforce challenges that even impacts construction and citing, it’s two years out.

Miller: I want to turn to Measure 110. It decriminalized drug possession in the state. The idea was that it would also make it easier for people to access treatment. But according to reporting from OPB and a lot of other places, that second part really hasn’t happened yet – citations that hopefully would encourage people into treatment, they’re often thrown away, sometimes right in front of a police officer. Then partly because of the shortage you’re talking about, even if someone does say, ‘All right, I will seek treatment,’ there isn’t necessarily treatment for them.

Do you have a sense for when the promise of supplying this, the demand for drugs treatment, when it’s actually going to be met?

Clarke: That’s a good question. I would say that it’s going to be iterative and so what we have to be able to do is to be innovative and creative and looking at what are some other emerging services and supports or practices that we can bring online that are more likely to be community-based, while waiting for this new level of capacity to come online.

Miller: What’s an example that you have in mind? I mean, what’s a community-based ‘stop gap?’

Clarke: So, you brought up culturally-specific and so I think about culturally-specific and culturally responsive services. Traditionally, the way that we treat individuals who are impacted by substance use issues and challenges is through the Western medicine model. A lot of times there’s not room, or it’s not traditional modes of healing in a lot of various Communities of Color are not necessarily considered.

Through this awareness of trying to be value based and value oriented in what we bring on because we’re humans, there’s been this effort, and I think we really saw it play out in the pandemic, of starting to support and fund and resource traditional modes of healing. So, for example, in the African-American community, it’s all about storytelling. It’s about singing, it’s about dancing, it’s about being in community. A lot of times, African-Americans when seeking support will go to their spiritual higher power. So really starting to be intentional in terms of partnering with faith-based organizations is an example to then carry out some of those traditional modes.

Miller: I asked earlier what different people’s ideas of success are and the starkest version was fewer people dying. I mean, it was as basic as that – someone did not die today. What’s your definition of success for your own job? You have the unenviable job of being in charge of behavioral health for the state at a time when there are twin enormous crises of substance use disorder and mental illness that are very public. And that’s one difference now – because of homelessness, a lot of this is more visible to many people than it maybe would have been 20 years ago, even five years ago. But I’m curious for you personally, what success is?

Clarke: I’d say that, first and foremost, my success is rooted in not hopes but what has to be done. For me, the approach to success is not based on one individual person; It’s a collective effort.

Reflecting on the issues that we’re seeing specific to fentanyl, it has to take a more intentional, collaborative approach. So besides just relying on the behavioral health system or the health care system, we have to also start to be more intentional and step into thought partnership with our first responders and with law enforcement. Because just as it was raised today, we are chasing the intersection of these new levels of lethal potency drugs, while also trying to chase the science to figure out how do we mitigate it?

So success to me is being able to have a menu of services and supports that allows someone to step into their journey of recovery and healing the way that they need to. I’d say that success for me is being able to begin to bring online and fund emerging practices that are not, like I said earlier, rooted necessarily in just Western medicine. Getting away from this, ‘it has to be either black or white.’ We are complex and we are unique and we cannot take a cookie-cutter approach to the services that we’re looking to bring on to be effective for those out there suffering.

Miller: And just briefly, we heard from Jim Laidler, this sort of chilling notion that maybe even worse pills are on the way. If we’re thinking upstream about the people who haven’t yet taken them…and who knows what else is there? How do we build a more resilient society, where people feel less of a need to escape from pain?

Clarke: That’s a really great question. I think that, what I will say is, that in the pandemic, we learned a lot about ourselves. I think that, at least from the behavioral health perspective, we were able to do things that we thought we never could do.

Part of it, quite frankly, we also have to take an emergency response approach to this issue specific to illicit substances because one life lost is too many.

Miller: Ebony Clarke. Thank you very much.

Clarke: Thank you.

Miller: That was Ebony Clarke, the director of behavioral health services for the Oregon Health Authority. She joined us at Saint Anthony’s Church recently as we focused on the Confederated Tribes of Grande Ronde’s Great Circle Recovery Clinics. Thanks very much to the Oregon Community Foundation for helping make this show and our whole solutions-oriented series possible, and to Father Pat at Saint Anthony’s Church.

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